Learnings from Project ORCHID's pioneering work on harm reduction in northeast India shows that scale up is possible even in resource poor and conflict ridden settings. A national dissemination workshop organized by Project ORCHID in Delhi saw sharing and discussion on best practices on harm reduction: reducing HIV risk among injecting drug users (IDUs).

Supported by Emmanuel Hospital Association (EHA) and funded by Avahan AIDS Initiative of the Bill and Melinda Gates Foundation, the project has done pioneering work on harm reduction in Manipur and Nagaland. As 10 years of good work comes to a completion in 2014, and the project transitions out and is being handed over to the government, "it is a time of celebration," said Ganesh Ramakrishnan, head of Avahan.

Project ORCHID (Organised Response for Comprehensive HIV Interventions in Selected High Prevalent Districts of Manipur and Nagaland) has been implementing harm reduction in Manipur and Nagaland since 2004. Interventions such as Needle Syringe Exchange Programmes (NSEP) and Opioid Substitution Therapy (OST), HIV testing and antiretroviral therapy (ART) access, have proved extremely effective in arresting the spread of HIV. Dissemination of learnings from the project will go a long way in scaling up harm reduction interventions in the rest of the country. Lov Verma, Secretary, Department of AIDS Control, New Delhi, said: "Initially, drug use was restricted to the metros and the North-East, but we are now seeing hotspots in Punjab, Haryana, Chhattisgarh, Kerala. Learnings from the North-East will be useful here."

Dr B Langkham, who has led Project Orchid over the last decade, has worked on drug use and the AIDS epidemic in the northeast India since the early beginnings in 1989. When the project began in 2004 the sociopolitical climate was not favourable and international donors were hesitant to invest, he said. "Avahan was a risk taker; we are the result of that risk. Harm reduction is not supported by the faith-based community, yet EHA is supporting us." He spoke of how important it is for those who work on drug use to "listen to the drug user."

ORCHID’s framework on scaling up harm reduction in India lays emphasis on the need to be science-based and have robust technical guidelines. Engaging local implementers, decentralized delivery, and community engagement are seen as crucial. The project has shown that harm reduction programmes can achieve scale even in resource-poor settings by adding locally relevant innovations, experts said. Programmes that are led, managed and owned by the community tap into local solutions and foster an enabling environment, they added.

Opioid Substitution Therapy (OST) has worked wonders for drug users. "It is like insulin for a person with diabetes," said Dr M Suresh Kumar, psychiatrist, who has worked over 30 years on substance use disorder. By taking care of withdrawal it makes the user functional so he can lead a normal life. OST involves substituting the opioid the drug user is using by methadone or buprenorphine given orally once a day in a clinical setting. This has led to reduced HIV incidence. For it to be successful, the coverage should be at least 40-50%, giving the right dose is critical. Providing HIV testing and ART along with it is the best way to stop sexual transmission, Dr Suresh said.

IDUs may put their partners at a higher risk for sexual transmission of HIV. If HIV among the IDU population is not addressed in time, it becomes a generalised epidemic, experts say, as the early northeast Indian experience has shown.

Currently there are 52 OST centres across 14 states in India. The government is setting a target of 300 centres by the end of this year. Between Manipur and Nagaland there are 29 OST centres reaching out to over 3,000 injecting drug users. There are an estimated 1,80,000 injecting drug users in the country.

Beneficiaries of OST say it is a miracle; their families call it 'gold'. G Charanjit Sharma, ex-user who now works with India HIV/AIDS Alliance says being on OST drug use becomes like a chronic disease that needs to be treated with some medical and psychosocial help. "It took care of withdrawal, I didn't have to go looking for money, there was no fighting and quarrelling with the family, my appetite improved and I started to look better," he says. Simon Beddoe, who benefited from OST in 1999, says a drug user will do desperate things for drugs – steal, sell sex, share needles. "When you are desperate you don’t think about risk. OST was a miracle for me – no withdrawal, no urge," says the ex-user who now works as an Advocacy Officer in the drug use and harm reduction programme of India HIV/AIDS Alliance in Delhi.

Across the IDU programme for HIV prevention community engagement has been vital. In fact, AIDS expert Dr Sundar Sundararaman says in the case of response to IDU, Government didn't invent the intervention; it was civil society who did it. Dr M Suresh Kumar adds that Orchid's singular achievement has been engaging and empowering the drug user community: "There is nothing more satisfying that seeing people who were once beneficiaries of the project now as leaders."

For experts who have seen HIV in the northeast India since its early beginnings, and how effective response has helped contain it, the dissemination workshop was also an opportunity to look back. Dr Swarup Sarkar, AIDS expert who was the first Indian epidemiologist to describe the IDU related spread of HIV in northeast India remembers 1989 when they first saw 20 HIV positive samples in Manipur. "I look back and see friends lost and relapsed. At that time no hospital would admit HIV positive people who were mostly drug users," he said.

Dr Langkham remembers how jails were full of drug users, there was a lot of stigma, and people were dying. "I saw a need in my own backyard, I knew I had to respond,” he says. At that time he was working in Churachandpur as District Immunisation Officer. Having served in the public health system over 17 years, Dr Langkham moved on to work on drug use in the mid-90s, offering home-based care, treating abscess, training teams to offer home-based care to a community no one wanted to touch. More than 20 years later, Dr Langkham, 61, says it has been a very satisfying journey.

Years of conflict and challenging geographical landscape have made work in the northeast India complex. Phalguni Singh, of Dedicated People's Union, a group of ex-IDUs, remembers how in 2003-2005 the law and order situation in Moreh, on the Myanmar border, was volatile. IDUs became soft targets for both insurgents and paramilitary forces, forcing them to become a hidden community. Access to prevention services were nil and there was a lack of concern about HIV, he says, adding that even if services were there no one would come to take them out of fear.

Experts acknowledge how the environment in the northeast India has changed over the last decade, thanks primarily to Project Orchid's advocacy with church leaders, formal and informal forces, and the Government. "From being seen as criminals, users are now seen as people with a disorder who need support from society. The programme has got support from the Church. Needle-syringe exchange was seen as a crime, today there is no backlash to it," says Dr Sundararaman.

Across the world, drug users say criminalisation of drug use is a hindrance to access. Sam Nugraha, Asian Network of People Who Use Drugs (ANPUD), has said elsewhere how many countries in Asia are implementing harm reduction approaches – most likely led by the Health Ministry – but in the same countries the law enforcement are not really on the same page. "Criminalisation prevents drug users from accessing services," he emphasised.